Correspondence
High-quality health
systems: time for a
revolution in research
and research funding
The launch of two landmark
publications1,2 on the quality of care
in the world’s poorest populations,
including The Lancet Global Health
Commission on high-quality health
systems in the Sustainable Development
Goals era (September, 2018),1 is a
welcome addition to the ongoing
discourse on improving the quality of
care that these populations receive.
The authors of these reports rightly
high­light that the push for universal
health coverage in low-income and
middle-income countries, as well as
the setting of disease-specific targets,
will not achieve their desired impact on
health outcomes without a focus on
improving quality. As such, improving
quality of care is essential to meet the
health-related targets of the Sustainable
Development Goals.1
With a focus on populational
needs, Margaret Kruk and colleagues1
align themselves with WHO’s
responsiveness framework, which
includes aspects such as dignity,
autonomy, confidentiality, clear
communication, prompt attention,
and quality of amenities. 3 These
factors are intimately linked to quality
and trust, go beyond the immediate
health-care needs people might
have (eg, medicines and access to
diagnostics), and focus on underlying
issues related to provision of a high-
quality service. This refocusing is in line
with the view of strengthening instead
of merely supporting the development
of health systems in low-income and
middle-income countries.4
Although the authors of the
Commission1 do mention the roles of
funders and researchers in creating
a high-quality health system, we
believe that this discussion should
go further because a “revolution” in
approaches, methods, and funding
is needed. To improve the quality
www.thelancet.com/lancetgh Vol 7 March 2019 e303
of health systems, it is necessary to
thoroughly understand the needs of
the community, as well as the existing
conditions in which care is delivered
and received. Accomplishing this
task will require formative research
with financial support from funders.
As stated in the Crossing the global
quality chasm report, 2 “co-design”
by communities and providers is
needed for the responses from these
formative studies to be adapted
locally. Researchers will therefore
have to work with communities
through participatory processes
to develop appropriate responses
and interventions tailored to the
communities’ actual needs. 5 They
will need skills in communication
and engagement to carry out this
work successfully, as well as being
able to deal with the uncertainty of
not knowing what interventions they
will implement in particular settings
at the start of a grant or research
project because the most appropriate
interventions will only become
apparent at the end of the formative
research stage.
Researchers and the academic
establishment will have to adapt
because not all studies will be
randomised trials and the usual
academic reward—publications
in high-profile journals—will not
necessarily be the currency of these
research endeavours. Importantly,
researchers will be challenged on
their established approaches and
ideas if they truly want to engage
meaningfully in the co-creation of
health systems. Similarly, funders also
need to deal with these uncertainties
by allowing room for innovation
and development of interventions
grounded in the needs of the
communities they wish to impact.
The complexity of research will need
to be managed by both researchers and
funders, and multicomponent rather
than one-off interventions will be
required to this end. Such interventions
will add to the challenge of evaluating
current health systems by necessitating
the implementation of process
evaluations, in conjunction with the
measurement of traditional outcomes.
The Crossing the global quality
chasm report2 states that to improve
quality of health care “this shift will
require new skills, attitudes, and
culture among health-care providers
and new, more active roles for
patients and families in shaping,
evaluating, and delivering the care
they need”. Given the chronicity of
current challenges in health care,
these factors should align with the
principle of “careful and kind care”,6
which aims to minimise the potential
negative impacts of treatment on the
individual, while ensuring high quality
of care. We fully back such supportive
care from the perspectives of health-
care providers and the community
but also believe that researchers will
need new skills and attitudes and that
a change in the culture of funding
is essential. These changes require
both researchers and their funders to
take a more active role in focusing
on the actual needs of populations.
Moreover, researchers need to be
given the space and time necessary
to create the needed interventions
and evaluate them appropriately.
This shift in thinking, funding, and
support for research should result in
programmes and interventions that
have a true impact on the quality of
care provided to the world’s poorest
populations.
The COHESION (COmmunity HEalth System
InnovatiON) Project is funded by the Swiss National
Science Foundation and the Swiss Development
Cooperation under the Swiss Program for Research
on Global Issues for Development. We declare no
competing interests.
Copyright © 2019 The Author(s). Published by
Elsevier Ltd. This is an Open Access article under the
CC BY-NC-ND 4.0 license.
*David Beran, François Chappuis,
Albertino Damasceno, Nilambar Jha,
Maria Amalia Pesantes,
Suman Bahadur Singh,
Claire Somerville, L Suzanne Suggs,
J Jaime Miranda, on behalf of the
COHESION Project
david.beran@unige.ch
 Correspondence

Division of Tropical and Humanitarian Medicine,

University of Geneva and Geneva University
Hospitals, Geneva 1205, Switzerland (DB, FC);
Faculty of Medicine, Eduardo Mondlane University,
Maputo, Mozambique (AD); BP Koirala Institute of
Health Sciences, Dharan, Nepal (NJ, SBS); CRONICAS
Centre of Excellence in Chronic Diseases,
Universidad Peruana Cayetano Heredia, Lima, Peru
(MAP, JJM); Gender Centre, Graduate Institute of
International and Development Studies, Geneva,
Switzerland (CS); BeCHANGE Research Group,
Institute of Public Communication, Università della
Svizzera Italiana, Lugano, Switzerland (LSS); Swiss
School of Public Health, Zurich, Switzerland (LSS);
and School of Medicine, Universidad Peruana
Cayetano Heredia, Lima, Peru (JJM)
1 Kruk ME, Gage AD, Arsenault C, et al.
High-quality health systems in the Sustainable
Development Goals era: time for a revolution.
Lancet Glob Health 2018; 6: e1196–252.
2 National Academies of Sciences, Engineering,
and Medicine. Crossing the global quality
chasm: improving health care worldwide.
Washington, DC: The National Academies
Press, 2018.
3 de Silva A. A framework for measuring
responsiveness. https://www.who.int/
responsiveness/papers/paper32.pdf (accessed
Oct 5, 2018).
4 Chee G, Pielemeier N, Lion A, Connor C.
Why differentiating between health system
support and health system strengthening is
needed. Int J Health Plann Manage 2013;
28: 85–94.
5 Beran D, Lazo-Porras M, Cardenas MK, et al.
Moving from formative research to
co-creation of interventions: insights from a
community health system project in
Mozambique, Nepal, and Peru.
BMJ Global Health 2018; 3: e001183.
6 Montori V. Why we revolt: a patient revolution
for careful and kind care. Rochester, MN:
Patient Revolution, 2017.

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